2017 Kamper/LIT Application

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KAMPER - 5 to 17 yrs of age 
   LIT (
Leader-In-Training)
17 & 18 yr. olds
   NOTE: 17yr olds have the option to attend as a kamper or LIT
 *
KAMPER/LIT PERSONAL INFORMATION
Gender *
Treatment *
In order to ensure the safety of all of kampers, I grant permission for Kay's Kamp's Medical Director to review my kamper's medical records at A.I. DuPont Hospital for Children or other treating hospital. (ALL INFORMATION WILL BE KEPT STRICTLY CONFINDENTIAL) *
T-Shirt Size
Siblings
 
 PARENT/GUARDIAN INFORMATION
Contact by Email
Are you interested in joining a private Kamp Facebook group to see daily photos, videos, and messages of your child throughout the week of Kamp? (If you check "yes" you will be notified at the above email address regarding access) *
MEDICAL INSURANCE
Has kamper ever been convicted of a crime
NOTE: A prior conviction or accusation is not an automatic bar from attending Kay's Kamp. The type of conviction or accusation will be evaluated by Kay's Kamp administration before any decision is made.
 If "Yes", Explain
No. Convictions
Offense
Sentence
Date
Does kamper use special equipment?
Does Kamper have any difficulty controlling their bladder/bowels during the day or night? *
 Please explain
Yes
No
 
KAMPER/LIT MEDICAL INFORMATION
Has your child had a bone marrow/stem cell transplant? *
Does Kamper have a PortaCath?
Does Kamper have a Central Line?
* Parents/Guardians must provide supplies for Central Line care and flushing for the week of Kamp.
 
 
KAMPER/LIT MEDICAL HISTORY
 
Have you/Do you:   (If yes, please explain)
1. Have any recent injury, illness or infectious disease?
 
2. Have a chronic or recurring illness/injury?
 
3. Been hospitalized in the past 18 months?
 
4. Had surgery in the past 18 months?
 
5. Have headaches or migraines?
 
6. Had a head injury?
 
7. Been knocked unconscious?
 
8. Wear glasses, contacts or protective eyewear?
 
9. Passed out during or after exercise?
 
10. Been dizzy during or after exercise?
 
11. Had seizures?
 
12. Had chest pain during or after exercise?
 
13. Had high blood pressure?
 
14. Been diagnosed with a heart murmur?
 
15. Had back problems?
 
16. Had problems with joints (knees, ankles, etc.)?
 
17. Have any skin problems (itching, hives, rash, acne)?
 
18. Have diabetes?
 
19. Have asthma?
 
20. Had mononucleosis in the past 12 months?
 
21. Had problems with diarrhea/constipation?
 
22. Have problems sleep walking?
 
23. If female, have abnormal menstrual history?
 
24. Had/have an eating disorder?
 
25. Have ADD/ADHD?
 
26. Have developmental delays?
 
27. Have mental health issues? (depression, anxiety, etc.)
 
28. Use any tobacco products (including E-cigarettes)? *
 
ALLERGIES: Please list all known allergies including medications, food, environmental, insect, hay fever, asthma, etc. SYMPTOMS/SIDE EFFECTS: Please list side effects including rash, hives, difficulty breathing, shock, etc.
 Allergy toSymptoms/Side Effects
Allergy
Allergy
Allergy
Allergy
Allergy
MEDICAL DIAGNOSIS
 Please list any additional medical diagnosis that have been made on your child
Medical Diagnosis
Approx. Date of diagnosis
Any complications/changes
Medical Diagnosis
Approx. Date of diagnosis
Any complications/changes
Medical Diagnosis
Approx. Date of diagnosis
Any complications/changes
Medical Diagnosis
Approx. Date of diagnosis
Any complications/changes
SURGERY
 Please list any surgical procedures your child may have had during their lifetime.
Surgery
Date (most recent first)
Complications resulting from surgery
Surgery
Date
Complications resulting from surgery
Surgery
Date
Complications resulting from surgery
Surgery
Date
Complications resulting from surgery
Specialists/Therapists
 Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Name
Specialty
Specific issues
Date of last appointment
Name
Specialty
Specific issues
Date of last appointment
Name
Specialty
Specific issues
Date of last appointment


KAY'S KAMP REQUIRES UPDATED IMMUNIZATIONS FOR EACH KAMPER EACH YEAR! 
Please identify any of the following diseases 
your child has been diagnosed with in the past
 Approximate Date
Measles
German Measles
Mumps
Chicken Pox
Shingles
Whooping Cough
MEDICAL IMMUNIZATIONS

Please list dates of most recent immunizations
 Date
Tetanus (DTaP, DT, Td, or Tdap)
H1N1 vaccine, if eligible
2016/2017 Influneza vaccine
Varicella
If the Kamper/LIT has recently had a PPD test, please complete the following.
Tuberculin Test, Most recent result

 
Has or will the kamper/LIT or any member of the immediate family traveled outside the United States within six (6) months of July 2017? *
 
KAMPER/LIT MEDICATIONS
 
 
The medical staff will store and administer any medications needed during the kamp session.  Please send all medications to Kamp with your child in their original container with written instructions.  It is expected that each family will supply in advance any routine medications needed.
 
Please have your doctor submit the order if your child requires any infusions medications.  It is necessary for you to arrange the transport of these medications to Kamp with your healthcare team.
 
If your child is on therapy, please send the most recent blood counts to Kamp with your child for comparision to any counts which may be needed at Kamp.

 
NOTE
 
KAMPER APPLICANTS
Please complete the Parent/Guardian Certification and Authorization. Then SUBMIT your application at the bottom of this form!
 
LIT APPLICANTS
Please scroll down and complete the LIT portion of this application.

Kamper Parent/Guardian Certification and Authorization

As the responsible parent/guardian of the applicant, I hereby certify that the application information provided on this form is current, true and correct to the best of my knowledge.

I hereby waive, release and discharge any and all claims for damages, death, personal injury or property damage which I may have or which may hereafter accrue to me as a result of my child's participation in Kay's Kamp activities. Your agreement discharges in advance Kay's Kamp and all of its agents, representatives, volunteers and employees from any and all liability, claims, costs, expenses and/or damages (collectively referred to as “liability”) arising out of or connected in any way with my child's participation in the activities of Kamp, even through that liability may arise out of negligence or carelessness on the part of the person or entities mentioned above.

I further understand that serious accidents occasionally occur during Kamp activities, and that participation in Kamp activities occasionally sustain mortal or serious personal injuries and/or property damage as a consequence thereof.  Knowing the risks of Kamp activities, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence or carelessness) might otherwise be liable to my child or to me (or to my heirs or assigns) for damages.

I further agree to indemnify and hold harmless Kay's Kamp in the event or for any other damages any other person, property damages or entity, other than the undersigned, brings an action for the death or personal injuries of my child, as a result of my child's participation in Kay's Kamp activities.

I understand that Kay's Kamp accepts no responsibility for the loss, damage or theft of my child's property.

I agree that if I should not be readily available during the Kamp week, I will advise and keep the Kamp Administration team informed of where I can be contacted in the event of an emergency.

I understand that Kay's Kamp maintains an accident insurance policy on kampers attending the 2017 summer session and that all claims under this policy must be submitted within 30 days of the occurrence of the accident. This policy is in addition to and not in place of health or accident insurance maintained by you.

I recognize and understand that Kay's Kamp is operated as a charitable organization and that my child and I are receiving all of the benefits of Kay's Kamp with minimal or no cost to us.

I hereby give my permission to the Kay's Kamp medical team to administer routine and prescribed medications/treatments for my child as well as any emergency care required. In case of a medical and/or surgical emergency, I authorize Kay's Kamp medical staff to render to my child or to arrange for my child to receive any x-rays, anesthetic, medical, dental, surgical diagnosis, treatment, and hospital care which is deemed advisable by and is rendered under, the supervision of any physician, dentist, surgeon or nurse practitioner licensed to practice in the State of Delaware. I agree to be responsible for all medical transportation and related charges incurred on behalf of my child. I further agree that no Kay's Kamp employee, agent or volunteer will be responsible for injuries or damages arising from the provisions of such emergency treatment or transportation.

I acknowledge that reporters, photographers and other members of the media may attend Kay's Kamp in order to increase the awareness about Kay's Kamp and its programs. I grant permission for my child to be interviewed, photographed and filmed by any member of the media at Kay's Kamp. I understand that Kay's Kamp is not responsible for the content of the media coverage and that my child will not be paid for any media work.

Kay's Kamp and its representatives have absolute permission to use my child's image in a photograph or video that pertains to the lawful programs and activities of the Kamp.

I authorize my child to engage in all Kamp Activities, except as noted in writing by me or by the physician or PNP completing the Physician/PNP Recommendations and Restrictions form for my child.

 

BY CHECKING THIS BOX, I CERTIFY THE ABOVE APPLICATION INFORMATION THAT I HAVE PROVIDED IS CURRENT, TRUE AND CORRECT AND I HAVE READ AND AGREE TO THE FORGOING TERMS AND CONDITIONS *
BY CHECKING THIS BOX, I AGREE TO CONTACT MY KAMPER'S/LIT'S PHYSICIAN TO HAVE THE  PHYSICIAN/PNP FORM COMPLETED PRIOR TO KAMP. (NO kamper/LIT will be allowed to attend Kay's Kamp without a completed PNP form. It is the resposibility of the parent/guardian to follow up with the physician) *
 *
 PLEASE COMPLETE THE FOLLOWING INFORMATION
PARENT/GUARDIAN NAME
CHILD'S NAME
RELATIONSHIP
DATE
Please be sure to print the PHYSICIAN/PNP RECOMMENDATIONS AND RESTIRCTIONS AT KAMP as that form will need to be completed by your kamper/LIT's Physician or Pediatric Nurse Practitioner and provided to Kay's Kamp prior to the beginning of Kamp.  Please click the link on the website application page.

Leaders in Training (LIT) Applicants ONLY - Please complete the following

 
To be considered for the LIT program, the applicant must complete the application process, have a personal interview with the LIT Director or Kamp Director, have a successful criminal background check (18yrs and older), have successful reference checks and attend staff orientation as scheduled.
 

Applicants for the Leader-In-Training Program must be 17-18 years of age. They will reside and interact with a group of kampers during the week and be responsible for the health and safety of each assigned kamper in the cabin. They will encourage and motivate kampers to participate in all activities. Responsibilities during the week include:

-Assist counselors to ensure order, safety and discipline among kampers

-Knowing the whereabouts of assigned kampers at all times

-Being a role model for the kampers at all times

-Assist kampers with oral and personal hygiene, assuring that kampers are appropriately dressed for the scheduled activity

-Report any concerns of a health nature immediately to the Lead Counselor

-Report any problems or concerns about the safety to the Lead Counselor

-Actively participate with assigned kampers in all activities, remembering that the kampers' needs come first.

Please use the space provided below to answer questions that relate to your interest in being an LIT.

 
Please list three (3) people who are not your relatives to serve as references. 

Please include one (1) former employer (if you have previous work experience) and two (2) people that can attest to your character and ability to work in different situations.

 
NOTE: Remember when listing a reference that they need to be readily available for contact by Kay's Kamp staff.  If we are unable to reach a reference, you will be required to provide an additional name.
LIT APPLICANTS ONLY
 BACKGROUND CHECK INFORMATION
Driver's License or State ID Name
Driver's License or State ID Number
License or State ID
Expiration Date


LIT Parent/Guardian Certification and Authorization

As the responsible parent/guardian of the applicant, I hereby certify that the application information provided on this form is current, true and correct to the best of my knowledge.

I hereby waive, release and discharge any and all claims for damages, death, personal injury or property damage which I may have or which may hereafter accrue to me as a result of my child's participation in Kay's Kamp activities. Your agreement discharges in advance Kay's Kamp and all of its agents, representatives, volunteers and employees from any and all liability, claims, costs, expenses and/or damages (collectively referred to as “liability”) arising out of or connected in any way with my child's participation in the activities of Kamp, even through that liability may arise out of negligence or carelessness on the part of the person or entities mentioned above.

I further understand that serious accidents occasionally occur during Kamp activities, and that participation in Kamp activities occasionally sustain mortal or serious personal injuries and/or property damage as a consequence thereof.  Knowing the risks of Kamp activities, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence or carelessness) might otherwise be liable to my child or to me (or to my heirs or assigns) for damages.

I further agree to indemnify and hold harmless Kay's Kamp in the event or for any other damages any other person, property damages or entity, other than the undersigned, brings an action for the death or personal injuries of my child, as a result of my child's participation in Kay's Kamp activities.

I understand that Kay's Kamp accepts no responsibility for the loss, damage or theft of my child's property.

I agree that if I should not be readily available during the Kamp week, I will advise and keep the Kamp Administration team informed of where I can be contacted in the event of an emergency.

I understand that Kay's Kamp maintains an accident insurance policy on kampers attending the 2017 summer session and that all claims under this policy must be submitted within 30 days of the occurrence of the accident. This policy is in addition to and not in place of health or accident insurance maintained by you.

I recognize and understand that Kay's Kamp is operated as a charitable organization and that my child and I are receiving all of the benefits of Kay's Kamp with minimal or no cost to us.

I hereby give my permission to the Kay's Kamp medical team to administer routine and prescribed medications/treatments for my child as well as any emergency care required. In case of a medical and/or surgical emergency, I authorize Kay's Kamp medical staff to render to my child or to arrange for my child to receive any x-rays, anesthetic, medical, dental, surgical diagnosis, treatment, and hospital care which is deemed advisable by and is rendered under, the supervision of any physician, dentist, surgeon or nurse practitioner licensed to practice in the State of Delaware. I agree to be responsible for all medical transportation and related charges incurred on behalf of my child. I further agree that no Kay's Kamp employee, agent or volunteer will be responsible for injuries or damages arising from the provisions of such emergency treatment or transportation.

I acknowledge that reporters, photographers and other members of the media may attend Kay's Kamp in order to increase the awareness about Kay's Kamp and its programs. I grant permission for my child to be interviewed, photographed and filmed by any member of the media at Kay's Kamp. I understand that Kay's Kamp is not responsible for the content of the media coverage and that my child will not be paid for any media work.

Kay's Kamp and its representatives have absolute permission to use my child's image in a photograph or video that pertains to the lawful programs and activities of the Kamp.

I authorize my child to engage in all Kamp Activities, except as noted in writing by me or by the physician or PNP completing the Physician/PNP Recommendations and Restrictions form for my child.

If my application is for a Leader-In-Training (LIT) position, I authorize Kay's Kamp to obtain information pertaining to any charges my child may have for federal and state criminal law violations. This information will include convictions committed upon minors and adults and will be gathered from any law enforcement agency of this state or any other state or federal government to the full extent permitted by law. I understand that such access is for the purpose of considering my application as a volunteer and that I expressly DO NOT authorize the Kamp, its' directors, officers, employees or other volunteers to disseminate this information in any way to any other individual, group, agency, organization, or corporation.

BY CHECKING THIS BOX, I CERTIFY THE ABOVE APPLICATION INFORMATION THAT I HAVE PROVIDED IS CURRENT, TRUE AND CORRECT AND I HAVE READ AND AGREE TO THE FORGOING TERMS AND CONDITIONS *
BY CHECKING THIS BOX, I AGREE TO CONTACT MY KAMPER'S/LIT'S PHYSICIAN TO HAVE THE  PHYSICIAN/PNP FORM COMPLETED PRIOR TO KAMP. (NO kamper/LIT will be allowed to attend Kay's Kamp without a completed PNP form. It is the resposibility of the parent/guardian to follow up with the physician) *
 *
 PLEASE COMPLETE THE FOLLOWING INFORMATION
PARENT/GUARDIAN NAME
CHILD'S NAME
RELATIONSHIP
DATE
Please be sure to print the PHYSICIAN/PNP RECOMMENDATIONS AND RESTIRCTIONS AT KAMP as that form will need to be completed by your kamper/LIT's Physician or Pediatric Nurse Practitioner and provided to Kay's Kamp prior to the beginning of Kamp.  Please click the link on the website application page.